Every finding on record at 1st Choice Home Health Agency, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 03/19/26. Standard deficiencies cited.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Binder and staff interview, the Agency failed to include names and contact information for staff, contracted staff, patients' physicians, and volunteers in the emergency preparedness communication plan. This has a potential to affect all staff and patients receiving services. Findings include: . 1.The Emergency Preparedness binder was reviewed on 03/17/26. The binder lacked documentation of contact information for staff, contracted staff, patients' physicians and volunteers. 2. During an interview with the Administrator Designee and Director of Nursing on 03/18/26 at 10:15 AM the above findings were confirmed.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on the Agency's Emergency Preparedness binder review and staff interview, the Agency failed to provide training and maintain documentation of training for the Emergency Preparedness Plan since 2022. This has the potential to affect all staff and patients of the Agency. Findings include: . 1. The Emergency Preparedness binder was reviewed on 03/17/26. The binder lacked documentation of employee training on the Emergency Preparedness plan for the years 2023, 2024, 2025 and 2026. 2. During an interview with the DON and Adiminstrator Designee on 03/18/26 at 10:15 AM the above findings were confirmed. The DON stated the Agency educated on the Emergency Preparedness Plan upon hire, as needed and annually, however there is no documentation of the education.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Binder and staff interview the Agency failed to complete the analysis of the activation of the emergency plan in February of 2025. The Agency also failed to implement an additional test of the Plan by February 2026. Findings include: . 1.The Emergency Preparedness binder was reviewed on 03/17/26. The binder included documentation that the Emergency Plan was activated 02/19/25. The documentation of the event lacked an after action plan or analysis of the activation. The binder lacked an additional full scale exercise, mock drill or table top exercise the following year. 2. During an interview with the DON and Administrator Designee on 03/18/26 at 10:15 AM the above findings were confirmed.

A recertification survey was conducted in conjunction with the evaluation of the Emergency Preparedness requirements, on 03/16/26. Standard level deficiencies cited. Abbreviations: SN = Skilled Nursing Pt. / Pts. = Patients / Patients POC / PsOC = Plan of Care / Plans of Care DON = Director of Nursing # = number OASIS = Outcome and Assessment Information Set MD = Medical Doctor lbs = pounds wk = week O2 = oxygen PT = Physical Therapy OT = Occupational HHA = Home Health Aide MSW = Medical Social Worker % = percent

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Error Summary report and staff interview, the Agency failed to submit the OASIS assessments within 30 days after the assessment was completed. Findings include: . 1.The Error Summary report was reviewed on 03/16/26 at 10:00 AM. The report included 114 of 134 as late submissions. 79.72% of the OASIS reports submitted were more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing and the Administrator Designee on 03/18/26 at 1:15 PM, the Director of Nursing and Administrator Designee confirmed the above finding.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, for 1 of 2 discharged records reviewed (Pt. #7), the Agency failed to ensure that a comprehensive assessment was updated at discharge. Findings include: 1. Pt. #7 was admitted to Home Health Services on 11/15/25, with the diagnosis of Parkinson’s disease. The clinical record was reviewed on 03/16/26. The clinical record included the SN last visit dated 02/09/26. The clinical record include a Physician order dated 02/11/26, indicating: ".... Pt. discharged from skilled Nursing services. Physical therapy to continue per plan of care...." The PT (Physical Therapy) discharge note dated 03/05/26, indicating reason for discontinued service due to no further authorization. The clinical record lacked documentation that a comprehensive assessment was updated at discharge. 2. During an interview with the DON and Administrator Designee on 03/18/26 at 11:40 AM, the DON confirmed the above findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interviews, in 5 of 7 (Pts. #1,3, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure the PsOC were followed. Findings include: 1. Pt. #1 was admitted to Home Health Services on 02/03/26 with the diagnosis of Hemiplegia following Cerebral Infarction affecting Left Nondominant side. The clinical record was reviewed on 03/17/26. The clinical record included a POC effective 02/03/26 to 04/03/26, that required “….Dietitian ….1”. The same POC required, HHA frequency of 1/week x 1 week 2/week x 8 weeks. The clinical records lacked Home Health Aide visits for the week of 02/03/26 (week 1) and week of 02/08/26 (week 2). As of 03/18/26, there was no modification order or communication as to why the services were not provided as ordered. X. Pt. #7 was admitted to Home Health Services on 11/15/25, with the diagnosis of Parkinson’s disease. The clinical record was reviewed on 03/16/26. The clinical record included the POC effective 11/25/25 to 01/13/26, that required “….Dietitian 1….” As of 03/18/26, there was no modification order or communication as to why the service was not provided as ordered. X. During interviews with the DON and Administrator Designee on 03/18/26 between 10:15 AM to 12:30 PM, the DON confirmed the above findings. _. Pt. #3 was admitted to Home Health Services on 02/27/26 with diagnosis of fracture to right lower leg. The clinical record was reviewed on 03/17/26 and included a POC dated 02/27/26 to 04/27/26. The POC included an order for OT to Evaluate and Treat and an order for SN to asses O2 on room air every visit. During an interview with the DON on 03/18/26 at 10:15 AM she stated if the doctor orders therapy services for the patient, the therapy is to go out and evaluate the patient within 48 hours of SOC. As of 03/18/26, the clinical record lacked an OT Evaluation. The SN visit note dated 03/11/26 lacked an O2 assessment as ordered in the POC. _. Pt. #5 was admitted to Home Health Services on 11/03/25 with a diagnosis of malignant neoplasm of right ovary. The record included a POC dated 01/02/26. The POC included an order for a Dietician. As of 03/18/26, the clinical record lacked a visit from a Dietician. The clinical record also included an order dated 02/11/26 for PT. As of 03/18/26, the clinical record lacked a PT evaluation for the time frame after 2/11/26. _.Pt. #6 was admitted to Home Health Services on 10/17/25 with the diagnosis of Trauma subderal hematoma without loss of consciousness. The clinical record was reviewed on 03/16/26. The clinical record included a POC dated 10/17/25. The POC included an order for SN visits one time a week for 9 weeks. The clinical recorded documented missed visits for the weeks of 10/19, 10/26, 11/02 and 11/09. The record lacked MD notification of the missed visits and lacked any modification orders for the SN frequency. The POC frequency for SN was not followed.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical records reviewed and staff interview for 4 of 7 clinical records reviewed (Pts. # 5, 1, 7 and 2), the Agency failed to include an individualized and complete plan of care. Findings include: Pt. #2 was admitted to Home Health Services on 10/05/26 with a diagnosis of Type 2 Diabetes Mellitus with foot ulcer. The clinical record was reviewed on 03/17/26. The record included a POC for a certification period of 02/02/26 to 04/02/26. The POC lacked updated wound care interventions from the physician order dated 02/20/26. During an interview with the Director of Nursing and the Administrator Designee on 03/18/26 at 1:15 PM, the Director of Nursing and Administrator Designee confirmed the above finding.Findings include: X. Pt. #1 was admitted to Home Health Services on 02/03/26 with the diagnosis of, but not limited to Hemiplegia following Cerebral Infarction affecting Right Nondominant side, Muscle Wasting and Atrophy, Right shoulder, Muscle Wasting and Atrophy, Essential (primary) Hypertension, Depression, Moderate Protein-calorie Malnutrition, Other Abnormalities of Gait and Mobility, Cognitive Communication Deficit, Dysphagia, Other Symbolic Dysfunctions, Unspecified Visual Loss, Aortic Aneurysm of Unspecified Site, without Rupture. The clinical record was reviewed on 03/17/26. The clinical record included a POC effective 02/03/26 to 04/03/26, that required: “Notify physician of:….Fasting blood sugar greater than (>) 200 or less than () 250 or less than () lbs or less than (<) lbs.” These PsOC, lacked the Pt. specific weight parameters to notify Physician. The same PsOC, included the following medications: “….Eliquis…Visine….Carbidopa-Levodopa, Vitamin D3…Senna-Plus…Pravastatin…Pramipexole Dihydrochloride….Metformin….Fish Oil….Fenofibrate….Carbidopa-Levodopa….Flomax…Aspirin…Propanolol….” and required “….SN to assess blood sugar via finger stick every visit prior to insulin administration….”, Pt. #7 did not have insulin medication orders. The POC effective 11/15/25 to 01/13/26,included “…. HHA: 1/wk x 9 wk….Home Health Aide (freq) [text field] 3 wk x 8 for assistance….” The POC was inaccurate to include 2 different HHA frequency orders. _. Pt. #5 was admitted to Home Health Services on 11/03/25 with a diagnosis of Malignant Neoplasm of Right Ovary. The clinical record was reviewed on 03/17/26 and inlcuded a POC dated 01/02/26. The POC documented Displacement of Nephrostomy Catheter as the primary diagnois for the certification period of 01/02/26 to 03/02/26. The POC lacked interventions for the Nephrostomy Catheter, care and patient specific interventions on input and output for this patient. The clinical record lacked a POC for the certification period beginning 03/03/26. During an interview with the Administrator designee on 03/17/26 a request was made for the current POC. An undated document was provided as the POC. The POC lacked patient information, clinical data inlcuding diagnoses, and patient specific interventions.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical records reviewed and staff interview for 2 of 7 (Pts. #5 and 7) the Agency failed to coordinate care to meet the patients' needs. Pt. #7 was admitted to Home Health Services on 11/03/25 with a diagnosis of malignant neoplasm of right ovary. The clinical record included a POC dated 01/02/26 that included SN services. The SN visit notes dated 02/12/26 and 2/19/26 documented a declince in patient status. The SN notes documented the DON was notified. The clinical record lacked coordination with the patient's primary care provider in regards to the decline in status. The POC also included HHA services. The HHA visit note dated 03/03/26 documented, "...noted blisteres filled with fluid around the anus. Nurse was notified." The HHA visit noted dated 03/04/26 documented, "...Patient has open sores around the anus, and the surrounding area is hard and sensitive to touch...pictures were taken and sent to DON... per request..." The HHa visit noted dated 03/06/26 documented, "...open sores to anal area.." The clinical record lacked documentation of coordination with the primary care provider in regards to change in patient status. The POC also included an order for MSW services. The MSW visited the patient on 02/06/26. Referrals were made for catholic charities homemaker, and meals on wheels. The clinical record lacked further documentation with the MSW for follow up on coordination of services. X. Pt. #7 was admitted to Home Health Services on 11/15/25, with the diagnosis of Parkinson’s disease. The clinical record was reviewed on 03/16/26. The clinical record included a Physician order dated 01/06/26 for MSW (Medical Social Worker) to evaluate for community resources. The clinical record included an MSW evaluation dated 01/07/26, and 2 MSW visit notes dated 01/16/26 and 01/26/26, that documented Social worker attempted to contact Pt. and wife, leaving a voicemail and requesting a return call. The last SN visit note dated 02/05/26, indicated Pt. requested to see a social worker. The clinical record lacked further documentation that the Social worker or Nurse contacted the Agency to ensure Pt.’s request for Social worker services were provided. X. During interviews with the DON and Administrator Designee on 03/18/26 between 10:15 AM to 12:30 PM, the DON confirmed the above findings.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on patient clinical records review, Agency's Admission Folder review and staff interview, in 7 of 7 (Pts. # 1-7) clinical records reviewed, the Agency failed to provide the name of the current Director of Nursing to Pts. and / or their representative on Admission. Findings include: . 1.The Agency's Admission Folder was reviewed on 03/16/26. The Admission Folder failed to include the name of the current Director of Nursing. 2. The following patient clinical records were reviewed between 03/16/26 and 03/18/26. The clinical records lacked documentation that the patient or representative were provided the name of the current Director of Nursing. Pt. # 1 SOC 02/03/26 Pt. # 2 SOC 10/05/25 Pt. # 3 SOC 02/27/26 Pt. # 4 SOC 03/11/26 Pt. # 5 SOC 11/03/25 Pt. # 6 SOC 10/17/25 Pt. # 7 SOC 11/15/25 3. During an interview with the Director of Nursing and the Administrator Designee on 03/18/26 at 1:15 PM, the Director of Nursing and the Administrator Designee confirmed the above findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the Agency failed to ensure the Administrator was responsible for all day to day operations including ensuring the Agency's address is documented correctly on all Agency documents. Findings include: 1.During entrance interview on 03/16/26 at 9:45 AM, the Agency's Administrator Designee confirmed the Agency's address as "18400 Maple Creek Drive, Suite 600..." 2. The Home Health Agency Renewal Licensure Application signed by the administrator on 09/30/25 and the Admission Folder were reviewed on 03/16/26, the licensure application and the folder included the Agency's address as "18400 Maple Creek Drive, Ste 600..." 3. Clinical records were reviewed 03/16/26 through 03/18/26, 7 of 7 clinical records, listed below (Pts. # 1-7) included PsOC, that documented the Agency's address as "18400 Maple Creek Court, Ste 900..." Pt. #1 SOC 02/03/26 Pt. #2 SOC 10/05/25 Pt. #3 SOC 02/27/24 Pt. #4 SOC 03/11/26 Pt. #5 SOC 11/03/25 Pt. #6 SOC 10/17/25 Pt. #7 SOC 11/15/25 4. The Emergency Preparedness binder was reviewed 03/17/26, the binder included a document titled "Agency Information" that documented the Agency's address as "18400 Maple Creek Dr, Ste 900..." 5. During an interview with the Director of Nursing and the Administrator Designee on 03/18/26 at 1:15 PM, the Director of Nursing and the Administrator Designee confirmed the above findings. The Administrator Designee confirmed the address documentation on the PsOC and Emergency Preparedness document was inaccurate and the correct address as 18400 Maple Creek Dr. Suite 900.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview for 1 of 7 (Pt. #5) clinical records reviewed the Agency failed to incorporate accurate clinical notes into the clinical record. Findings include: . 1.Pt. #5 was admitted to home health services on 11/03/25 with the diagnosis of malignant neoplasm to the right ovary. The clinical record included a POC dated 01/02/26 that inlcuded SN visit frequency two times a week for three weeks, and then one time a week for five weeks. The SN visited the patient per order throughout the certification ending 03/02/26. The SN visit notes from 1/11/26 through 02/25/25 (12 visits) included documentation in the section titled, "Respiratory" that documented, "...cough: nonproductive...comments: no cough..." The SN visit notes dated 01/13/26, 01/17/26 and 1/20/26 include documentation in the section titled, "Digestive Nutrition" that documented, "...Abd Girth: 38 inches...Comments:...Patient's adominal girth has decreased from 39 inches to 37 inches since her nephrostomy tubes were replaced..." The SN visit notes dated, 1/26/26, 01/29/26, 02/03/26, 02/05/26, 02/10/26, 02/12/26 and 02/17/26 include documentation in the section titled, "Digestive Nutrition" that documented "...Abd Girth: 39 inches...Comments:...Patient's adominal girth has decreased from 39 inches to 37 inches since her nephrostomy tubes were replaced..." The SN visit notes dated, 02/19/26, 02/25/26 and 03/05/26 include documentation in the section titled, "Digestive Nutrition" that documented "...Abd Girth: 40 inches...Comments:...Patient's adominal girth has decreased from 39 inches to 37 inches since her nephrostomy tubes were replaced..." The clinical notes included conflicting documentation. During an interview with the DON on 03/18/26 at 10:30 AM, she confirmed the documentation in the SN notes above regarding abdonminal girth and cough were conflicting and therefore inaccurate. 2. During an interview with the DON and Administrator Designee on 03/18/26 at 10:45 AM, the above findings were cofirmed.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview, for 1 of 2 (Pt. #6) discharged records reviewed the Agency failed to complete and send a discharge summary to the patient's primary care provider within 5 days of discharge. Findings include: . 1.Pt. #6 was admitted to Home Health Services on 10/17/26 with the diagnosis of Trauma subdural hematoma without loss of consciousness. The clinical record included a discharge OASIS dated 11/21/25 that included "discharged from all services" completed by the SN. The record lacked an SN discharge summary that was sent to the patient's physician with in 5 days from discharge. 2. During an interview with the DON and Administrator designee on 03/18/26 at 10:15 AM the above findings were confirmed.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Agency’s Emergency Plan and staff interview, it was determined the Agency failed to develop and maintain an emergency communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s Emergency Plan was reviewed on 11/29/22 at 12:30 PM. The plan’s communication list lacked names and contact information for all staff members, entities providing services under arrangement, and Pt. Physicians. 2. During an interview on 11/30/22 at 1:00 PM with the Alternate Administrator, it was confirmed the communication list lacked the required names and contact information for all staff members, entities providing services under arrangement, and Pt. Physicians.

Recertification survey conducted on 12/1/22. 42 CFR 484.80(f)(3): Eligible training and competency evaluation organizations. Determination has been made that this Agency is not in compliance with the Conditions of Participation for: 42 CFR 484.70 Infection prevention and control 42 CFR 484. 105 Organization and administration of services Based on observation and record review an IJ was identified for the provision of skilled nursing services. The Agency did not have skilled nurses to provide SN services during the survey. The Agency Supervisor and the Alternate Agency Supervisor were not available to ensure SN services were provided to all Agency's Pts. and to provide clinical supervision. Therefore, the Agency is precluded from conducting aide training and/or competency evaluations for 24 months effective 12/1/22. This applies even if the agency is not currently conducting aide training and/or competency evaluation. Abbreviations: x = times w = week # = number E = Employee AM = morning () = greater than PRN = as needed SN = Skilled Nurse POC = Plan of care BP = blood pressure MD = Medical Doctor SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening HHA = Home Health Aide Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist PTA = Physical Therapy Assistant OT = Occupational Therapy/Therapist PPE = Personal Protective Equipment COVID=19 = Coronavirus disease 2019 NOMNC = Notice of Medicare Non-Coverage

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, observation during a home visit and staff interview, it was determined that the Agency failed to inform the Pt./patient's representative in writing of the disciplines to furnish care, and the frequency of visits. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 11/28/22 at 10:30 AM to 11/29/22 at 9:25 AM. The records lacked documentation of the Pt./patient's representative consent to the disciplines that will furnish care, and the frequency of the proposed visits. Pt. #1 SOC: 9/19/22. Pt. #2 SOC: 11/25/22. Pt. #3 SOC: 1/21/22. Pt. #4 SOC: 2/11/22. Pt. #5 SOC: 6/13/22. Pt. #6 SOC: 2/10/22. Pt. #7 SOC: 12/21/21. 2. Pt. #2. SOC 11/25/22. Diagnoses Chronic Systolic (Congestive) Heart Failure, Cellulitis of Right Lower Limb, and Cellulitis of Left Lower Limb. A home visit was conducted on 11/30/22 at 10:00 AM with the Agency Supervisor. During the home visit, the patient's admission folder was reviewed and lacked documentation that the Pt./patient's representative was informed of the disciplines to provide care, and the frequency of the proposed visits. 3. During an interview with the Alternate Administrator on 11/30/22 at 2:50 PM, and the Administrator with the Alternate Administrator on 12/1/22 at 12:52 PM, it was confirmed the Agency failed to inform the Pt./patient's representative in writing of the disciplines to furnish care, and the frequency of visits to be provided.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: A. Based on a review of the Agency’s Pt. admission packet, clinical record review, and staff interview, it was determined the Agency failed to ensure Pts. were informed of the Agency’s policy on transfer and discharge. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission packet was reviewed on 11/28/22 at 11:00 AM. The packet lacked information regarding the Agency’s transfer and discharge policy. 2. The following clinical records were reviewed from 11/28/22 at 12:30 PM to 11/29/22 at 9:25 AM: Pt. #1. SOC 9/19/22. Pt. #2. SOC 11/25/22. Pt. #3. SOC 1/21/22. Pt. #4. SOC 2/11/22. Pt. #5. SOC 6/13/22 Pt. #6. SOC 2/10/22. Pt. #7. SOC 12/21/21. The above records all lacked documentation the Pts./patient's representative were informed of the Agency’s transfer and discharge policy. 3. Pt. #7's record included documentation of Pt. #7's Agency services were billed to Medicare. The record also contained the POC effective 12/21/21 to 2/18/22, which contained the Physician’s order: “SN 2w1, 1 w8.” The record also included the SN discharge summary dated 1/27/22, which was the 6th week of service. This discharge summary contained: “…Discharged from Agency due to not in network.” This POC also included the Physician's order: "PT to Evaluate and Treat..." The PT evaluation was completed 1/5/22 and included the frequency and duration "1wk7." The PT discharge summary was dated 1/27/22, during the Patient's 5th week of PT. This discharge summary indicated: "Reason for Discharge: Change in insurance (not in network). This POC also included the Physician's order dated 1/17/22: "OT to evaluation and treat..." The record contained the OT evaluation, completed during the Pt. visit on 1/24/22, which contained the treatment plan: "1wk1, 2w3." This was the only OT visit the Pt. received. The record lacked documentation that an OT discharge summary completed. The record also lacked a Physician's order to discharge the Pt. The record lacked documentation that the Pt. was notified of the discharge. The record contained the Patient's face sheet, indicating the Pt. was covered by Medicare. The record lacked a signed, Notice of Medicare Non-Coverage consent, indicating Pt. #7 was notified she was going to be discharged prior to the completion of her home health agency services due to payment reasons, and also lacked any indication the Agency attempted to transfer the Patient's care to another agency. 4. The Agency policy titled "Discharge/Transfer Procedure" was reviewed on 11/30/22 at 1:00 PM. The policy required: "At least 2 days before the discharge (final) visit, the patient/client will receive the notice of discharge with instructions on the purpose of the form. The patient will be required to sign the Notice of Medicare Non-Coverage (NOMNC)...Prior to discharge, the Attending Physician shall be notified...the Patient/Family will be informed of the discharge, orally and in writing, at least five (5) days prior to discharge..." 5. During an interview on 11/30/22 at 2:50 PM with the Alternate Administrator, and the Administrator with the Alternate Administrator on 12/1/22 at 12:52 PM, the above findings were confirmed.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure a comprehensive initial assessment was conducted by a RN within 48 hours of a Physician’s referral for home health services. This was found in 4 of 7 (Pts. #1, 7, 2 and 5) clinical records reviewed. 3. Pt. #2. SOC 11/25/22. Diagnoses: Chronic Systolic (Congestive) Heart Failure, Cellulitis of Right Lower Limb, and Cellulitis of Left Lower Limb. The clinical record was reviewed on 11/28/22 at 12:30 PM. The record contained the SOC comprehensive assessment dated 11/25/22 and POC effective 11/25/22, indicating services were initiated on 11/25/22. The referral dated 11/22/22 and faxed to the Agency on 11/22/22 contained documentation the Pt. was being discharged from an inpatient facility on 11/22/22 and required the Agency to start service. The Agency initiated service 3 days after receiving the referral. The Agency failed to initiate service within 48 hours of the inpatient discharge. 4. Pt. #5. SOC 6/13/22. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The closed clinical record was reviewed on 11/29/22 at 9:25 AM. The record contained lacked documentation that the Pt. was discharged from an inpatient facility or received a Physician ordered SOC date. The record lacked a referral for the Agency to initiate service on 6/13/22. It cannot be determined who the referral source was and/or whether service was initiated within 48 hours upon receipt of a referral. 5. During an interview with the Alternate Administrator on 11/30/22 at 2:50 PM, and 12/1/22 at 12:52 PM with the Administrator and Alternate Administrator, the above findings were confirmed. Findings include: 1. Pt. #1. SOC 9/19/22. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 11/28/22 at 12:45 PM. The record contained the Physician’s referral for home health services, faxed to the Agency on 9/15/22. The record also included the initial comprehensive assessment, conducted by the RN on 9/19/22, 4 days after the Physician’s referral. 2. Pt. #7. SOC 12/21/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/28/22 at 3:00 PM. The record contained the Physician’s referral for home health services, faxed to the Agency on 12/17/21. The record also included the initial comprehensive assessment, conducted by the RN on 12/21/21, 4 days after the Physician’s referral.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, interview and observation during a home visit and staff interview, it was determined the Agency failed to ensure the POC included pertinent instructions related to wound care. This was found in 1 of 2 (Pt. #2) clinical records reviewed, wherein the Pt. required wound care. Findings include: 1. Pt. #2. SOC 11/25/22. Diagnoses: Chronic Systolic (Congestive) Heart Failure, Cellulitis of Right Lower Limb, and Cellulitis of Left Lower Limb. The clinical record was reviewed on 11/28/22 at 12:30 PM. The record contained the POC effective 11/25/22 requiring: "SN to assess/evaluate wound(s) at each dressing change and PRN for signs/symptoms of infection..." The POC lacked a description of the wound care to be provided, and the frequency of the wound care. 2. A home visit was conducted on 11/30/22 at 10:00 AM with the Agency Supervisor. During the home visit, the Pt. stated the RN gave instructions to her to clean both legs with soap and water while showering daily, pat legs dry, apply Betamethasone cream (medication observed: Betamethasone cream 0.05%) to both legs, wrap legs first with gauze wraps, then ace wraps. The Pt. stated the RN instructed her that the wraps need to be on day and night, remove only for showering. The POC lacked a description of the wound care to be provided, and the frequency of the wound care. 3. During an interview with the Administrator and Agency Supervisor on 11/30/22 at 2:50 PM, and 1the Administrator with the Alternate Administrator on 2/1/22 at 12:52 PM, it was confirmed the POC lacked instructions related to wound care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to provide all services as order by the Physician in the POC. This was found in 4 of 7 (Pts. #1, 3, 4, and 5) clinical records reviewed. Findings include: 1. Pt. #1. SOC 9/19/22. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 11/28/22 at 12:45 PM. The record contained the POC effective 9/19/22 to 11/17/22, which included the Physician’s order: “…Notify Physician of: Pulse greater than (>) 120 or less than () 160 or less than () 90 or less than () 160 or less than () 90 or less than () 100 or less than () 24 or less than () 160 or less than () 90 or less than () 160 or less than () 90 or less than (<) 50..." The SN visit note dated 6/19/22 included BP of 136/99 and 122/93. The record lacked documentation the SN notified the Physician regarding the diastolic BP greater than 90. 5. The Agency policy titled “Physician’s Plan of Treatment” was reviewed on 11/29/22 at 11:00 AM. The policy required: “…Any changes in the Physician’s plan of treatment shall be made in writing and signed and dated by the Physician, or by the Registered Nurse…pursuant to the verbal orders of the Physician, which will be mailed to him for his signature, which is required within thirty (30) days…” 6. During an interview with the Alternate Administrator on 11/30/22 at 2:50 PM, and the Administrator with the Alternate Administrator on 12/1/22 at 12:52 PM, it was confirmed the Agency failed to provide service as indicated on the PoC.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: A. Based on clinical record review, staff interview, Pt. interview and Agency policy review, it was determined the Agency failed to coordinate care with staff, the Pt. and the Physician regarding a known Pt. case of COVID-19. This was found in 1of 5 (Pt. 1) clinical records reviewed, wherein multiple disciplines provide care and/or services, and this has the potential to affect all staff providing direct Pt. care/services. Findings include: 1. Pt. #1. SOC 9/19/22. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 11/28/22 at 12:45 PM. The record contained an HHA missed visit note dated 10/21/22, which included: “COVID-19 Building on lockdown.” This note included documentation the Supervisor was notified. During an interview on 11/29/22 at 10:20 AM, E #3 stated she is the HHA assigned to Pt. #1, and on 10/21/22 received a phone call from Pt. #1’s family member, stating the facility in which the Pt. resides was on lockdown due to COVID-19. E #3 then called and notified E#7 (Office Manager/CNA) and E #1 (Pt. #1’s RN Case Manager). E #3 received a phone call from E #1 on 11/4/22, that stated Pt. #1 had now tested positive for COVID-19. E #3 stated she hasn’t seen Pt. #1 since the phone call she received from Pt. #1’s family member on 10/21/22 and has not received instructions from the Agency on when she may resume providing HHA care to Pt #1. The record included a SN communication note dated 10/27/22, which contained: “Patient not seen this week due to the...is on lockdown due to COVID outbreak. Then today...her family member called, and stated Patient came down with COVID today.” The record lacked documentation the SN received/wrote a Physician’s order to place Pt. #1’s SN, PT, OT, and HHA services on hold due to the Patient’s...facility being placed on lockdown due to COVID-19; however, the record included documentation the SN missed a visit on 10/26, the HHA missed twice weekly visits beginning 10/21/22 to 11/16/22, and the OT missed visits on 10/28/22 and 11/1/22-all documented as due to the COVID-19...facility lockdown/COVID-19 diagnosis of Pt. #1. The record also lacked documentation E #7 or E #1 notified the PT, PTA, or the OT providing services to Pt. #1 that Pt. #1’s... facility was on lockdown due to COVID-19, or that Pt. #1 was reported to have COVID-19. The record also lacked a Physician’s order regarding when Agency SN, HHA, PT, and OT services could resume providing services to Pt. #1. The record included documentation the PTA saw the Pt. on 10/26/22, 11/4/22, and 11/11/22. The PTA visit notes lacked documentation the PTA was made aware Pt. #1’s... facility was on lockdown for COVID-19 or that the Pt. was positive for COVID-19. The record also contained documentation the OT saw the Pt. on 10/22/22. This OT visit note lacked documentation the OT was made aware Pt. #1’s... facility was on lockdown for COVID-19. 2. The Agency policy titled “Clinical Record Contents” was reviewed on 11/29/22 at 11:20 AM. The policy required: “…The clinical record includes the following information…evidence of coordination of services/care provided by the organization with others who may be providing service/care…” 3. The Agency policy titled "Coordination of Services" was reviewed on 11/30/22 at 2:00 PM. The policy required: "...The staff Professional Nurse is responsible for the following: The professional coordination of all home care services. Maintaining channels of communication between/among all active caregivers...The Agency coordinates care by: Integrating services, whether services are provided directly or under arrangement, to ensure the identification of patient needs and factors that could affect Patient safety and treatment effectiveness, and the coordination of care provided by all disciplines..." 4. During an interview with the Alternate Administrator on 11/30/22 at 2:50 PM, the above findings were confirmed.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: A. Based on a review of the Agency’s Pt. admission packet, clinical record review, Pt. interview, and staff interview, it was determined the Agency failed to ensure Pts. were informed of the Agency Supervisor’s name and contact information. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission packet was reviewed on 11/28/22 at 11:00 AM. The packet lacked information regarding the Agency Supervisor’s name and contact information. 2. The following clinical records were reviewed, beginning 11/28/22 at 12:30 PM to 11/29/22 at 9:25 AM: Pt. #1. SOC 9/19/22. Pt. #2. SOC 11/25/22. Pt. #3. SOC 1/21/22. Pt. #4. SOC 2/11/22. Pt. #5. SOC 6/13/22 Pt. #6. SOC 2/10/22. Pt. #7. SOC 12/21/21. The above records all lacked documentation the Pts. were informed of the Agency Supervisor’s name and contact information. 3. A home visit was conducted for Pt. #2 on 11/30/22 at 10:00 AM, along with the Agency Supervisor. The Pt. stated she had never met the Agency Supervisor and did not know who the Agency Supervisor was up until introduced to her during this home visit. 4. During an interview on 11/30/22 at 1:00 PM with the Alternate Administrator, the above findings were confirmed.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: A. Based on clinical record review, staff interview, Pt. interview and Agency policy review it was determined, the Agency failed to ensure staff follow infection control practices for COVID-19 positive Pts. and failed to develop policies and procedures to prevent the spread of COVID-19, and a method for processing COVID-19 staff exemption requests. This has the potential to affect all Pts. and staff providing direct Pt. care/services. 1. The agency failed to ensure staff follow infection control practices for COVID-19 positive Pts. and failed to develop policies and procedures to prevent the spread of COVID-19, and a method for processing COVID-19 staff exemption requests. (G687) The cumulative effect of these failures resulted in an inability to ensure staff and Pts. were protected against the spread of COVID-19.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on clinical record review, staff interview, Pt. interview, Agency policy review, and staff interview, it was determined the Agency failed to ensure staff follow infection control practices for COVID-19 positive Pt. and failed to develop policies and procedures to prevent the spread of COVID-19 and failed to develop a method for processing COVID-19 staff exemption requests. This has the potential to affect all Pts. and staff providing direct Pt. care/services. 3. The Agency's "COVID-19 Management" binder was reviewed on 11/30/22 at 2:39 PM. The binder lacked documentation of a policy or procedure pertaining to the Agency's decision-making process of staff COVID-19 exemption requests. 4. The Agency policy titled “COVID-19 Guidance” was reviewed on 11/30/22 at 1:00 PM. The policy required: “…Client Assessment Prior to Visit…If you plan to visit in person, ask the client beforehand if they or a member of the household has a cough, shortness of breath, fatigue, aches and pains, sore throat, diarrhea/nausea, or a runny nose or have been diagnosed with COVID-19…If the client or household members have fever, cough, shortness of breath, fatigue, aches and pains, sore throat, diarrhea/nausea, or a runny nose, you should suspect COVID-19 infection and adhere to the following: For all non-critical services, reschedule until after the client or household members have been released from isolation, which means that: At least 10 days have passed since their symptoms first appeared, and they have not had a fever for at least 24 hours (without the use of fever-reducing medicine) and other symptoms have improved (for example, improved cough or shortness of breath). People who are seriously immunocompromised may need to be in isolation for longer. They should consult their health care provider. For all critical services that cannot be postponed, use all recommended personal protective equipment (PPE)…” 5. During an interview with the Alternate Administrator on 11/30/22 at 2:50 PM, and the Administrator with the Alternate Administrator on 12/1/22 at 12:52 PM, it was confirmed the Agency failed to comply with its policy regarding COVID-19 guidance and ensure the policy for COVID-19 vaccinations for staff was complete. Findings include: 1. Pt. #1. SOC 9/19/22. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 11/28/22 at 12:45 PM. The record contained a HHA missed visit note dated 10/21/22, which included: “COVID-19 Building on lockdown.” This note included documentation the Supervisor was notified. During an interview on 11/29/22 at 10:20 AM, E #3 stated she is the HHA assigned to Pt. #1, and on 10/21/22 received a phone call from Pt. #1’s family member, stating the Patient’s facility in which the Pt. resides was on lockdown due to COVID-19 E #3 then called and notified E#7 (Office Manager/CNA) and E # 1 (Pt. #1’s RN Case Manager). E #3 received a phone call from E #1 on 11/4/22, who stated Pt. #1 had now tested positive for COVID-19. E #3 stated she hasn’t seen Pt. #1 since the phone call she received from Pt. #1’s family member on 10/21/22 and has not received instructions from the Agency on when she may resume providing HHA care to Pt #1. The record also included an SN communication note dated 10/27/22, which contained: “Patient not seen this week due to the Assisted Living is on lockdown due to COVID outbreak. Then today, her family member called, and stated Patient came down with COVID today.” The record lacked documentation the SN received/wrote a Physician’s order to place Pt. #1’s SN, PT, OT, and HHA services on hold due to the Patient’s... facility being placed on lockdown due to COVID-19; however, the record included documentation the SN missed a visit on 10/24, the HHA missed twice weekly visits beginning 10/21/22 to 11/16/22, and the OT missed visits on 10/28/22 and 11/1/22--all documented as due to the COVID-19... facility lockdown/COVID-19 diagnosis of Pt. #1. The record lacked documentation E #7 or E #1 notified the PT, PTA, or the OT providing services to Pt. #1 that Pt. #1’s AL facility was on lockdown due to COVID-19, or that Pt. #1 was reported to have COVID-19. The record lacked a Physician’s order regarding when Agency SN, HHA, PT, and OT services could resume providing services to Pt. #1. The record included documentation the PTA saw the Pt. on 10/26/22, 11/4/22, and 11/11/22. On the 10/26/22 and the 11/4/22 visits, the Pt. was pre-screened for exposure to persons with COVID-19, as well as for symptoms of COVID-19, and all questions were answered "no." The record lacked documentation the Pt. was screened for exposure/symptoms of COVID-19 prior to the visit on 11/11/22. The record lacked documentation the PTA was made aware Pt. #1’s... facility was on lockdown for COVID-19 or that the Pt. was positive for COVID19. The record also contained documentation the OT saw the Pt. on 10/22/22. The record lacked documentation the OT was made aware Pt. #1’s... facility was on lockdown for COVID-19, or that the Pt. was pre-screened for exposure/symptoms of COVID-19 prior to this visit. 2. During an interview with Pt. #1 on 11/29/22 at 10:30 AM, the Pt. stated her... facility was on lockdown beginning “the week before Halloween” due to an outbreak of COVI-19. Three tablemates whom Pt. #1 regularly sat in the dining room with all tested positive for COVID-19. Two of those residents are still hospitalized. All residents of the Assisted Living facility were confined to their rooms, and no visitors were allowed during the lockdown, which lasted “for about two weeks.” Pt. #1 stated she tested positive for COVID-19 herself during this time but was asymptomatic. Pt. #1 also stated she had a visit from two family members came to visit with her 11/26/22, one of whom subsequently tested positive for COVID-19 on 11/30/22.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: A. Based on staff interviews and observations, it was determined the Administrator failed to ensure an Agency Supervisor or an Alternate Agency Supervisor was available during and/or after the Agency's business hours; ensure qualified nursing staff is available during the Agency's operating hours and after hours for the availability of clinical supervision, and availability of nursing services provided. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Administrator failed to ensure an Agency Supervisor was available during the Agency's hours of operation and/or available after hours, for the supervision of clinical services. (G950) 2. The Administrator failed to ensure qualified nursing staff is available to provide nursing services and clinical supervision. (G952) The cumulative effect of these systemic practices resulted in the Agency's inability to provide appropriate clinical direction and oversight of patient care and services.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: A. Based on staff interviews and observation, it was determined the Administrator failed to ensure an Agency Supervisor or an Alternate Agency Supervisor was available during the Agency's operational business hours and/or available after business hours. This has the potential to affect all Pts. served by the Agency. Findings include: 1. An entrance interview was conducted with the Alternate Administrator and Office Manager on 11/28/22 at 10:27 AM. During the interview The Alternate Administrator stated the agency’s office hours are Monday through Friday from 9:00 AM to 5:00 PM, and that he and the Administrator assumes on-call responsibilities after routine business hours. The Alternate Administrator and Administrator are physical therapists, but do not provide direct Pt. care. The Administrator and the Office Manager stated direct patient care is provided by 2 nurses (E#1 and E#2); and the contracted staff provide PT, OT, speech therapy and medical social worker services. 2. During the same interview on 11/28/22, the Alternate Administrator stated the Agency Supervisor is on vacation and will return this Wednesday. The Office Manager stated the Alternate Agency Supervisor is on medical leave and will need to be off from work for 6 weeks. The Office Manager stated, the Agency have 2 active patients, the primary nurse is E#1 and the backup nurse is E#2. E#2 last saw the patients last week, E#1 is on a personal leave this week and E#2 the backup nurse is not available this week. 3. An interview was conducted with the Alternate Administrator and the Assistant Office Clerk on 11/30/22 at 12:53 PM. During the interview, the Assistant Office Clerk stated the Alternate Agency Supervisor left for medical leave on 10/13/22, and the Alternate Administrator agreed. The Administrator stated, "I’m not sure when she (Alternate Agency Supervisor) is going to return, she will need to be released by her doctor first.” The question was asked: "If a patient called right now with a clinical issue and requested a visit by the nurse today, who would provide the service? The Alternate Administrator responded, "I’m not sure… " During this survey, it was observed that the Agency failed to ensure an Agency Supervisor was available during the Agency's hours of operation and/or available after hours, for the supervision of clinical services. 4. During an interview with the Alternate Administrator and Assistant Office Clerk on 11/30/22 at 12:53 PM, and the Alternate Administrator on 11/30/22 at 3:45 PM, the Alternate Administrator confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: A. Based on a staff interviews, observation during and after a home visit, it was determined the Administrator failed to ensure qualified nursing staff was available during the Agency's operating hours and after hours, to ensure the provision of SN services and supervision. This has the potential to affect all services provided by the Agency. Findings include: 1. An entrance interview was conducted with the Alternate Administrator and Office Manager on 11/28/22 at 10:27 AM. During the interview, the Alternate Administrator stated the Agency’s office hours are Monday through Friday from 9:00 AM to 5:00 PM, and that the Administrator or Alternate Administrator assume on-call after regular office hours. The Alternate Administrator and Administrator are physical therapists. The Alternate Administrator stated, the Administrator, Alternate Administrator, Agency Supervisor and the Alternate Agency Supervisor do not provide direct Pt. care. The Administrator and the Office Manager stated SN services are provided by 2 nurses (E# and E#2). E#1 was on personal leave until Friday 12/2/22 and E#2 would not be available this week. During the same entrance interview, the Agency's Office Manager stated the Agency has 2 RNs that provide Pt. care, but neither will be available from Monday 11/28/22 to Thursday 12/1/22. The Agency lacked a SN to provide Pt. care during routine business hours and/or on-call if needed. 2. A home visit was conducted with the Agency Supervisor on 11/29/22 at 10:00 AM. During the home visit, the Agency Supervisor did not provide any Pt. care and participated only as an observer. The Agency Supervisor did not come into the Agency before or after the home visit. A telephone interview was conducted with the Agency Supervisor on 11/30/22 at 12:40 PM. The Agency Supervisor stated, "I left on vacation on 11/1/22. I only did the home visit today, because they said there was no one else to do it. I’m not coming into the office until Monday (12/5/22). I’m not scheduled to come back until Monday.” 3. It was observed that from Monday 11/28/22 at 9:00 AM to Thursday 12/1/22 at 4:00 PM, the Agency lacked an Agency Supervisor to provide direction, clinical supervision, and Pt. care if needed. 4. During an interview with the Alternate Administrator on 11/30/22 at 12:53 PM, the Alternate Administrator confirmed the Agency lacked the direction and clinical supervision of an Agency Supervisor.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to complete and/or ensure the Physician was sent a copy of the Transfer or Discharge Summary. This was found in 5 of 5 (Pts. #3, 4, 5, 6 and 7) closed/discharged clinical records reviewed. 4. Pt. #6. SOC 2/10/22. Primary Diagnosis: Unspecified Dementia without Behavioral Disturbance. The clinical record was reviewed on 10/28/22 at 2:15 PM. The record included the SN Discharge Summary dated 4/7/22, indicating this was the discharge date of the Pt. from Agency services. The record lacked documentation this SN Discharge Summary was sent to the Physician within 5 days of discharge. The record also contained the PT Discharge Summary dated 4/6/22. The record lacked documentation this PT Discharge Summary was sent to the Physician within 5 days of discharge. 5. Pt. #7. SOC 12/21/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/28/22 at 3:00 PM. The record also included the SN Discharge Summary dated 1/27/22. The record lacked documentation this Discharge Summary was sent to the Physician within 5 days of discharge. The record also contained the PT Discharge Summary dated 1/27/22. The record lacked documentation this Discharge Summary was sent to the Physician within 5 days of discharge. The also included the Physician's order dated 1/17/22: "OT to evaluation and treat..." The record contained the OT evaluation, completed during the Pt. visit on 1/24/22, which contained the treatment plan: "1wk1, 2w3." The record lacked documentation that an OT Discharge Summary was completed and sent to the Physician within 5 days of discharge. 6. During an interview with the Alternate Administrator on 11/30/22 at 2:50 PM, and the Administrator with the Alternate Administrator on 12/1/22 at 12:52 PM, the above findings were confirmed. Findings include: 1. Pt. #3. SOC 1/21/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 11/28/22 at 2:15 PM. The closed record contained the Discharge comprehensive assessment dated 4/11/22, indicating that Pt. #3 was discharged from the Agency. As of 11/28/22, the record/Agency lacked documentation that a copy of the Agency's Discharge Summary was sent to the Physician. 2. Pt. #4. SOC 2/11/22. Diagnoses: Unspecified Dementia Without Behavioral Disturbance and Essential (Primary) Hypertension. The clinical record was reviewed on 11/28/22 at 3:15 PM. The closed record contained the Discharge comprehensive assessment dated 4/9/22, indicating that Pt. #4 was discharged from the Agency. As of 11/28/22, the record/Agency lacked documentation that a copy of the Agency's Discharge Summary was sent to the Physician. 3. Pt. #5. SOC 6/13/22. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 11/29/22 at 9:25 AM. The closed record contained the Transfer assessment form dated 6/26/22, indicating the Pt. was transferred into an inpatient facility on 6/26/22. The record also contained a Discharge comprehensive assessment form dated 8/11/22, indicating Pt. #5 was discharged from the Agency due to being hospitalized since 6/26/22. As of 11/28/22, the record/Agency lacked documentation that a copy of the Agency's Inpatient Transfer assessment form and/or Discharge Summary form was sent to the Physician.